* = Required Information
1. POSITION VACANCY INFORMATION
Advertisement Employment Agency Friend Relative
Walk-in other
2. PERSONAL DATA
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
( Proof of citizenship or immigration status will be required upon employment )
Yes No
VMT Home Health Agency Hires Home Health Aides on a Part-time basis only. As a part-time employee, you are not entitled to any benefits. VMT Home Care Agency cannot guarantee any specific hours or days, you will be given work as it become available.
3. EDUCATION AND TRAINING, LANGUAGE CAPABILITIES
Yes No
Yes No
Yes No
Yes No
Yes No
4. WORK EXPERIENCE ( Provide employer's name, address and telephone, date of employment, hourly rate, average hours per week, name of supervisor, reason for leaving, supervisor, and your job title and duties )
No work experience, list 3 references that may be contacted regarding personal character
5. BACKGROUND INFORMATION
Yes No
CRIMINAL OFFENSES

The guidelines listed below are taken from the amendment to Title 22 of the District of Columbia Municipal Regulations (DCMR) Chapter 47. Health-Care Facility Unlicensed Personnel Criminal Background Check section 4701.1a, 4701.b, 4705.1a-4705.ee and 4705.2.

VMT is required by he above cited law to obtain a criminal Background Check on any prospective employee who is not a licensed professional or a volunteer who will be under the direct supervision of a licensed professional. The following is a list of offenses that may preclude you from working at VMT or the nursing homes ot programs it manages in the District of Columbia:

Murder, Attempted Murder, Manslaughter, Arson, Assault, Battery, Assault and Battery, Assualt with a dangerous weapon, Mayhem, Threats to do bodily harm, Burglary, Robbery, Kidnapping, Theft, Fraud, Forgery, Extortion, Blackmail, Trespass, Sexual Assault, Rape, Injury to Property, Illegal use of firearm, Illegal possession of firearm, Sexual Battery, Sexual Abuse, Child Abuse, Cruelty to Children, Unlawful distribution of a controlled substance, Unlawful possession of a controlled substance, Unlawful possession of a controlled substance with intent to distribute.
VMT may employ any individual who has been convicted of one (1) misdemeanor listed above, if:

( a ) The misdemeanor did not involve abuse or moral terpitude.
( b ) The conviction was more than ten (10) years prior ro the individuals application for employment with VMT.
( c ) There are no criminal matters pending against the individual at the time of application for employment with VMT
( d ) The individuals name is not on the Nurse Abuse Registry
Yes No
Murder Attempted Murder Manslaughter
Arson Assault Assault and Battery
Assault w/ dangerous weapon Mayhem Threats to do bodily harm
Burglary Robbery Kidnapping
Theft Fraud Forgery
Extortion Blackmail Tresspass
Sexual Assualt Rape Murder
Injury to Property Illegal use of firearm Illegal possession of firearm
Sexual Battery Sexual Abuse Child Abuse
Cruelty to Children Unlawful distribution of a controlled substance Unlawful possession of a controlled substance
Unlawful possession of a controlled substance with intent to distribute
6. SUBMISSION, CERTIFICATION, AND RELEASE OF INFORMATION
Read the following carefully before clicking the submit button below.

- I certify the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I consent to the release of information about my ability and fitness for VMT employment by my employers, schools, law enforcement agencies and other individuals and organizations, to investigators, personnel staffing specialists, and other authorized employees of VMT.

- This application for employment shall be considered for a period of time not to exceed 45 days. Every applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted during that time.
The applicant understands that neither this document nor any offer of employment from the employer constitutes an employment contract unless specific document to that affect is executed by the employer and employee in writing.

I certify that, to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith.

- In an event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate termination of my employment.

- I also understand that I am required to abide by all rules and regulations of the employer.
Security code